Mesothelioma, more precisely
malignant mesothelioma, is a rare form of
cancer
that develops from the protective lining that covers many of the body's
internal organs, the
mesothelium. It is usually caused by exposure to
asbestos.[1]

Most people who develop mesothelioma have
worked on jobs where they inhaled asbestos, or they have been exposed to
asbestos dust and fiber in other ways. It has also been suggested that
washing the clothes of a family member who worked with asbestos can put
a person at risk for developing mesothelioma.[3]
Unlike lung cancer, there is no association between mesothelioma and
smoking,
but smoking greatly increases the risk of other asbestos-induced
cancers.[4]
Those who have been exposed to asbestos have collected damages for
asbestos-related disease, including mesothelioma. Compensation via
asbestos funds or lawsuits is an important issue in law practices
regarding mesothelioma (see
asbestos and the law).

Environmental
exposures

Incidence of mesothelioma had been found to be
higher in populations living near naturally occurring asbestos. For
example, in central
Cappadocia, Turkey, mesothelioma was causing 50% of all deaths in
three small villages — Tuzköy, Karain and Sarıhıdır. Initially, this was
attributed to
erionite, a
zeolite mineral with similar properties to
asbestos. Recently, however, detailed epidemiological investigation
showed that erionite causes mesothelioma mostly in families with a
genetic predisposition.[18][19]
The documented presence of asbestos fibers in water supplies and food
products has fostered concerns about the possible impact of long-term
and, as yet, unknown exposure of the general population to these fibers.

Occupational

Exposure to asbestos fibers has been
recognized as an occupational health hazard since the early 20th
century. Numerous epidemiological studies have associated occupational
exposure to asbestos with the development of pleural plaques, diffuse
pleural thickening, asbestosis, carcinoma of the lung and larynx,
gastrointestinal tumors, and diffuse malignant mesothelioma of the
pleura and peritoneum. Asbestos has been widely used in many industrial
products, including cement, brake linings, gaskets, roof shingles,
flooring products, textiles, and insulation.

Commercial asbestos mining at Wittenoom,
Western Australia, occurred between 1945 and 1966. A cohort study of
miners employed at the mine reported that while no deaths occurred
within the first 10 years after
crocidolite exposure, 85 deaths attributable to mesothelioma had
occurred by 1985. By 1994, 539 reported deaths due to mesothelioma had
been reported in Western Australia.

Paraoccupational
secondary exposure

Family members and others living with asbestos
workers have an increased risk of developing mesothelioma, and possibly
other asbestos related diseases.[20][21]
This risk may be the result of exposure to asbestos dust brought home on
the clothing and hair of asbestos workers. To reduce the chance of
exposing family members to asbestos fibres, asbestos workers are usually
required to shower and change their clothing before leaving the
workplace.

Asbestos
in buildings

Many building materials used in both public
and domestic premises prior to the banning of asbestos may contain
asbestos. Those performing renovation works or
DIY activities may expose themselves to asbestos dust. In the UK use
of Chrysotile asbestos was banned at the end of 1999. Brown and
blue asbestos was banned in the UK around 1985. Buildings built or
renovated prior to these dates may contain asbestos materials.

Image of Metastatic mesothelioma

Diagnosing mesothelioma is often difficult,
because the symptoms are similar to those of a number of other
conditions. Diagnosis begins with a review of the patient's medical
history. A history of exposure to asbestos may increase clinical
suspicion for mesothelioma. A physical examination is performed,
followed by
chest X-ray and often
lung function tests. The X-ray may reveal pleural thickening
commonly seen after asbestos exposure and increases suspicion of
mesothelioma. A
CT (or CAT) scan or an
MRI is usually performed. If a large amount of fluid is present,
abnormal cells may be detected by
cytopathology if this fluid is
aspirated with a syringe. For pleural fluid, this is done by
thoracentesis or tube thoracostomy (chest
tube); for ascites, with
paracentesis or
ascitic drain; and for
pericardial[disambiguation
needed] effusion with
pericardiocentesis. While absence of malignant cells on cytology
does not completely exclude mesothelioma, it makes it much more
unlikely, especially if an alternative diagnosis can be made (e.g.
tuberculosis,
heart failure). Unfortunately, the diagnosis of malignant
mesothelioma by cytology alone is difficult, even with expert
pathologists.

Generally, a
biopsy
is needed to confirm a diagnosis of malignant mesothelioma. A doctor
removes a sample of tissue for examination under a microscope by a
pathologist. A biopsy may be done in different ways, depending on
where the abnormal area is located. If the cancer is in the chest, the
doctor may perform a
thoracoscopy. In this procedure, the doctor makes a small cut
through the chest wall and puts a thin, lighted tube called a
thoracoscope into the chest between two ribs. Thoracoscopy allows the
doctor to look inside the chest and obtain tissue samples.
Alternatively, the chest surgeon might directly open the chest (thoracotomy).
If the cancer is in the abdomen, the doctor may perform a
laparoscopy. To obtain tissue for examination, the doctor makes a
small incision in the abdomen and inserts a special instrument into the
abdominal cavity. If these procedures do not yield enough tissue, more
extensive diagnostic surgery may be necessary.

Immunohistochemical studies play an important
role for the pathologist in differentiating malignant mesothelioma from
neoplastic mimics. There are numerous tests and panels available. No
single test is perfect for distinguishing mesothelioma from carcinoma or
even benign versus malignant.

There are three histological types of
malignant mesothelioma: (1) Epithelioid; (2) Sarcomatoid; and (3)
Biphasic (Mixed). Epithelioid comprises about 50-60% of malignant
mesothelioma cases and generally holds a better prognosis than the
Sarcomatoid or Biphasic subtypes.[22]

Screening

There is no universally agreed protocol for
screening people who have been exposed to asbestos. Screening tests
might diagnose mesothelioma earlier than conventional methods thus
improving the survival prospects for patients. The
serum
osteopontin level might be useful in screening asbestos-exposed
people for mesothelioma. The level of soluble mesothelin-related protein
is elevated in the serum of about 75% of patients at diagnosis and it
has been suggested that it may be useful for screening.[25]
Doctors have begun testing the
Mesomark assay which measures levels of soluble
mesothelin-related proteins (SMRPs) released by diseased
mesothelioma cells.[26]

Treatment

The prognosis for malignant mesothelioma
remains disappointing, although there have been some modest improvements
in prognosis from newer chemotherapies and multimodality treatments.[28]
Treatment of malignant mesothelioma at earlier stages has a better
prognosis, but cures are exceedingly rare. Clinical behavior of the
malignancy is affected by several factors including the continuous
mesothelial surface of the pleural cavity which favors local metastasis
via exfoliated cells, invasion to underlying tissue and other organs
within the pleural cavity, and the extremely long latency period between
asbestos exposure and development of the disease. The histological
subtype and the patient's age and health status also help predict
prognosis. The epithelioid histology responds better to treatment and
has a survival advantage over sarcomatoid histology.[29]

Surgery

Surgery, by itself, has proved disappointing.
In one large series, the median survival with surgery (including
extrapleural
pneumonectomy) was only 11.7 months.[28]
However, research indicates varied success when used in combination with
radiation and chemotherapy (Duke, 2008). (For more information on
multimodality therapy with surgery, see below). A
pleurectomy/decortication is the most common surgery, in which the
lining of the chest is removed. Less common is an extrapleural
pneumonectomy (EPP), in which the lung, lining of the inside of the
chest, the hemi-diaphragm
and the
pericardium are removed.

Radiation

For patients with localized disease, and who
can tolerate a radical surgery, radiation is often given
post-operatively as a consolidative treatment. The entire hemi-thorax is
treated with radiation therapy, often given simultaneously with
chemotherapy. Delivering radiation and chemotherapy after a radical
surgery has led to extended life expectancy in selected patient
populations with some patients surviving more than 5 years. As part of a
curative approach to mesothelioma, radiotherapy is also commonly applied
to the sites of
chest drain insertion, in order to prevent growth of the tumor along
the track in the chest wall.

Although mesothelioma is generally resistant
to curative treatment with
radiotherapy alone, palliative treatment regimens are sometimes used
to relieve symptoms arising from tumor growth, such as obstruction of a
major blood vessel. Radiation therapy when given alone with curative
intent has never been shown to improve survival from mesothelioma. The
necessary radiation dose to treat mesothelioma that has not been
surgically removed would be very toxic.

Chemotherapy

Chemotherapy is the only treatment for
mesothelioma that has been proven to improve survival in randomised and
controlled trials. The landmark study published in 2003 by Vogelzang and
colleagues compared
cisplatin chemotherapy alone with a combination of cisplatin and
pemetrexed (brand name Alimta) chemotherapy in patients who had not
received chemotherapy for malignant pleural mesothelioma previously and
were not candidates for more aggressive "curative" surgery.[30]
This trial was the first to report a survival advantage from
chemotherapy in malignant pleural mesothelioma, showing a statistically
significant improvement in
median
survival from 10 months in the patients treated with cisplatin alone to
13.3 months in the group of patients treated with cisplatin in the
combination with pemetrexed and who also received supplementation with
folate and vitamin B12. Vitamin supplementation was given to
most patients in the trial and pemetrexed related side effects were
significantly less in patients receiving pemetrexed when they also
received daily oral folate 500mcg and intramuscular vitamin B12
1000mcg every 9 weeks compared with patients receiving pemetrexed
without vitamin supplementation. The objective response rate increased
from 20% in the cisplatin group to 46% in the combination pemetrexed
group. Some side effects such as nausea and vomiting,
stomatitis, and diarrhoea were more common in the combination
pemetrexed group but only affected a minority of patients and overall
the combination of pemetrexed and cisplatin was well tolerated when
patients received vitamin supplementation; both
quality of life and
lung function tests improved in the combination pemetrexed group. In
February 2004, the United States
Food and Drug Administration approved pemetrexed for treatment of
malignant pleural mesothelioma. However, there are still unanswered
questions about the optimal use of chemotherapy, including when to start
treatment, and the optimal number of cycles to give.

Cisplatin in combination with
raltitrexed has shown an improvement in survival similar to that
reported for pemetrexed in combination with cisplatin, but raltitrexed
is no longer commercially available for this indication. For patients
unable to tolerate pemetrexed, cisplatin in combination with gemcitabine
or vinorelbine is an alternative, or vinorelbine on its own, although a
survival benefit has not been shown for these drugs. For patients in
whom cisplatin cannot be used, carboplatin can be substituted but
non-randomised data have shown lower response rates and high rates of
haematological toxicity for carboplatin-based combinations, albeit with
similar survival figures to patients receiving cisplatin.[31]

In January 2009, the United States FDA
approved using conventional therapies such as surgery in combination
with radiation and or chemotherapy on stage I or II Mesothelioma after
research conducted by a nationwide study by Duke University concluded an
almost 50 point increase in remission rates.

Immunotherapy

Treatment regimens involving immunotherapy
have yielded variable results. For example, intrapleural inoculation of
Bacillus Calmette-Guérin (BCG) in an attempt to boost the immune
response, was found to be of no benefit to the patient (while it may
benefit patients with
bladder cancer). Mesothelioma cells proved susceptible to in vitro
lysis by LAK cells following activation by
interleukin-2 (IL-2), but patients undergoing this particular
therapy experienced major side effects. Indeed, this trial was suspended
in view of the unacceptably high levels of IL-2 toxicity and the
severity of side effects such as fever and cachexia. Nonetheless, other
trials involving interferon alpha have proved more encouraging with 20%
of patients experiencing a greater than 50% reduction in tumor mass
combined with minimal side effects.

Heated
Intraoperative Intraperitoneal Chemotherapy

A procedure known as heated intraoperative
intraperitoneal chemotherapy was developed by Paul Sugarbaker at the
Washington Cancer Institute.[32]
The surgeon removes as much of the tumor as possible followed by the
direct administration of a chemotherapy agent, heated to between 40 and
48°C, in the abdomen. The fluid is perfused for 60 to 120 minutes and
then drained.

This technique permits the administration of
high concentrations of selected drugs into the abdominal and pelvic
surfaces. Heating the chemotherapy treatment increases the penetration
of the drugs into tissues. Also, heating itself damages the malignant
cells more than the normal cells.

This technique is also used in patients with
malignant pleural mesothelioma.[33]

Multimodality
Therapy

All of the standard approaches to treating
solid tumors—radiation, chemotherapy, and surgery—have been investigated
in patients with malignant pleural mesothelioma. Although surgery, by
itself, is not very effective, surgery combined with adjuvant
chemotherapy and radiation (trimodality therapy) has produced
significant survival extension (3–14 years) among patients with
favorable prognostic factors.[34]
However, other large series of examining multimodality treatment have
only demonstrated modest improvement in survival (median survival 14.5
months and only 29.6% surviving 2 years).[28]
Reducing the bulk of the tumor with cytoreductive surgery is key to
extending survival. Two surgeries have been developed: extrapleural
pneumonectomy and pleurectomy/decortication. The indications for
performing these operations are unique. The choice of operation depends
on the size of the patient's tumor. This is an important consideration
because tumor volume has been identified as a prognostic factor in
mesothelioma.[35]
Pleurectomy/decortication spares the underlying lung and is performed in
patients with early stage disease when the intention is to remove all
gross visible tumor (macroscopic complete resection), not simply
palliation.[36]
Extrapleural pneumonectomy is a more extensive operation that involves
resection of the parietal and visceral pleurae, underlying lung,
ipsilateral diaphragm, and ipsilateral pericardium. This operation is
indicated for a subset of patients with more advanced tumors, who can
tolerate a pneumonectomy.[37]

Epidemiology

Although reported incidence rates have
increased in the past 20 years, mesothelioma is still a relatively rare
cancer. The incidence rate varies from one country to another, from a
low rate of less than 1 per 1,000,000 in Tunisia and Morocco, to the
highest rate in Britain, Australia and Belgium: 30 per 1,000,000 per
year.[38]
For comparison, populations with high levels of smoking can have a
lung cancer incidence of over 1,000 per 1,000,000. Incidence of
malignant mesothelioma currently ranges from about 7 to 40 per 1,000,000
in industrialized Western nations, depending on the amount of asbestos
exposure of the populations during the past several decades.[39]
It has been estimated that incidence may have peaked at 15 per 1,000,000
in the United States in 2004. Incidence is expected to continue
increasing in other parts of the world. Mesothelioma occurs more often
in men than in women and risk increases with age, but this disease can
appear in either men or women at any age. Approximately one fifth to one
third of all mesotheliomas are peritoneal.

Between 1940 and 1979, approximately 27.5
million people were occupationally exposed to asbestos in the United
States.[40]
Between 1973 and 1984, the incidence of pleural mesothelioma among
Caucasian males increased 300%. From 1980 to the late 1990s, the death
rate from mesothelioma in the USA increased from 2,000 per year to
3,000, with men four times more likely to acquire it than women. These
rates may not be accurate, since it is possible that many cases of
mesothelioma are misdiagnosed as adenocarcinoma of the lung, which is
difficult to differentiate from mesothelioma.

Notable people
who have lived for some time with mesothelioma

Although life expectancy with this disease is
typically limited, there are notable survivors. In July 1982,
Stephen Jay Gould was diagnosed with
peritoneal mesothelioma. After his diagnosis, Gould wrote "The
Median Isn't the Message"[46]
for Discover magazine, in which he argued that statistics such as
median survival are just useful abstractions, not destiny. Gould lived
for another 20 years, eventually succumbing to metastatic adenocarcinoma
of the lung, not mesothelioma. Author
Paul Kraus was diagnosed with
peritoneal mesothelioma in July 1997. He was given a prognosis of
less than a year to live and used a variety of complementary modalities.
He continued to outlive his prognosis and wrote a book about his
experience "Surviving Mesothelioma and Other Cancers: A Patient's Guide"[47]
in which he presented his philosophy about healing and the decision
making that led him to use
integrative medicine.

Legal issues

The first lawsuits against asbestos
manufacturers were in 1929. Since then, many lawsuits have been filed
against asbestos manufacturers and employers, for neglecting to
implement safety measures after the links between asbestos, asbestosis,
and mesothelioma became known (some reports seem to place this
as early as 1898). The liability resulting from the sheer number of
lawsuits and people affected has reached billions of dollars.[48]
The amounts and method of allocating compensation have been the source
of many court cases, reaching up to the United States Supreme Court, and
government attempts at resolution of existing and future cases. However,
to date, the US Congress has not stepped in and there are no federal
laws governing asbestos compensation.[49]

History

The first lawsuit against asbestos
manufacturers was brought in 1929. The parties settled that lawsuit, and
as part of the agreement, the attorneys agreed not to pursue further
cases. In 1960, an article published by Wagner et al. was seminal in
establishing mesothelioma as a disease arising from exposure to
asbestos.[50]
The article referred to over 30 case studies of people who had suffered
from mesothelioma in South Africa. Some exposures were transient and
some were mine workers. Prior to the use of advanced microscopy
techniques, malignant mesothelioma was often diagnosed as a variant form
of lung cancer.[51]
In 1962 McNulty reported the first diagnosed case of malignant
mesothelioma in an
Australian asbestos worker.[52]
The worker had worked in the mill at the asbestos mine in
Wittenoom from 1948 to 1950.

In the town of
Wittenoom, asbestos-containing mine waste was used to cover
schoolyards and playgrounds. In 1965 an article in the British Journal
of Industrial Medicine established that people who lived in the
neighbourhoods of asbestos factories and mines, but did not work in
them, had contracted mesothelioma.

Despite proof that the dust associated with
asbestos mining and milling causes asbestos-related disease, mining
began at Wittenoom in 1943 and continued until 1966. In 1974 the first
public warnings of the dangers of blue asbestos were published in a
cover story called "Is this Killer in Your Home?" in Australia's
Bulletin magazine. In 1978 the
Western Australian Government decided to phase out the town of
Wittenoom, following the publication of a Health Dept. booklet, "The
Health Hazard at Wittenoom", containing the results of air sampling and
an appraisal of worldwide medical information.

By 1979 the first writs for negligence related
to Wittenoom were issued against CSR and its subsidiary ABA, and the
Asbestos Diseases Society was formed to represent the Wittenoom victims.

In
Leeds,
England the
Armley asbestos disaster involved several court cases against
Turner & Newall where local residents who contracted mesothelioma
claimed compensation because of the asbestos pollution from the
company's factory. One notable case was that of June Hancock, who
contracted the disease in 1993 and died in 1997.[53]

There are two types of operations that may be offered to
patients with
pleural mesothelioma: pleurectomy/decortication and
extrapleural pneumonectomy. Pleurectomy/decortication is usually a
palliative (relieves symptoms without curing the cancer) operation in
cases where the entire tumor cannot be removed. It involves removal of
the pleura, where the majority of the tumor is located. It is effective
in controlling effusions (fluid accumulation) and decreasing the pain
caused by the cancer.

Extrapleural pneumonectomy is a far more extensive
operation and most often used in cases of localized mesothelioma. The
operation is technically difficult and performed only by surgeons in
large specialized medical centers. It involves removing the pleura,
diaphragm, pericardium, and the whole lung on the side of the tumor. The
patient must be in overall good health with no other serious illnesses
in order to tolerate the large operation. This operation is intended to
remove all or most of the cancer and some surrounding tissues as well.

Surgical treatment of peritoneal mesothelioma is often
performed either to help relieve symptoms or to attempt to remove the
tumor from the wall of the abdomen and other digestive organs. As with
pleural mesothelioma, these tumors are often too extensive to remove
completely. Similar operations can be performed to remove a mesothelioma
from the pericardium (the sac around the heart).

Mesothelioma Clinics - Cancer Centers

Anyone
whose life has been touched by mesothelioma understands that it is
necessary to locate the best care available for this rare form of
cancer, which is quite difficult to treat successfully. Therefore,
finding excellent doctors and other medical professionals who are
well-versed in mesothelioma care in particular is important and doing it
as quickly as possible is essential in order to best fight this disease.

Most of the major cancer centers in the United States and
the clinics devoted specifically to mesothelioma patients offer the
latest in treatments for the disease. In addition, these centers employ
physicians who stay abreast as to the particulars of these treatments,
offering the best chance for extending the patient’s life expectancy and
improving his/her overall quality of life during the fight against
asbestos-caused cancer.

Happily, as more and more dollars are funneled towards the
study of mesothelioma, more and more doctors are jumping on the
bandwagon of mesothelioma care, making it a bit easier to find
physicians who can provide everything the mesothelioma patient needs to
address their situation.

Finding a Mesothelioma Clinic/Cancer Center

Those who live in large cities are often fortunate enough
to have a major cancer center located in their proverbial backyard. Many
of these cancer centers can be found at the nation’s leading
universities. This makes mesothelioma treatment convenient for many,
with little travel required for doctor’s appointments, treatments, or
hospital stays.

Others are not so fortunate. mesothelioma patients who live
in rural areas or away from large cities may be required to travel in
order to find the best care available for their disease. Most of these
cancer centers understand that many patients travel quite a distance to
take advantage of their services and they are eager to assist the
patient and their family in making their visit(s) to the hospital as
easy as possible.

Hence, these cancer centers employ helpful staff members
that can assist with issues like long-term or short-term housing for
patients and their families, especially for those who will remain in
that location for treatment for an extended period of time. Most also
provide other essential information for family members who will be
staying with the patient including info on public transportation,
dining, shopping, and more.

In most cases, these cancer centers also offer emotional
and spiritual support for patients and families, including those nearby
and those who’ve traveled many miles to take advantage of the top-notch
services available at their institution.

A directory of
Mesothelioma
Clinics and Cancer Centers is listed below by state for your
convenience.

Veterans & Mesothelioma

Listen to audio about Veterans and Mesothelioma.

Veterans can develop
mesothelioma as a result of asbestos exposure during their
military service.

For decades, the men and women from all four branches
(Army,
Navy,
Air
Force and
Marines)
of the United States military have defended our country, both in
times of war and in times of peace. Veterans put their lives on
the line each and every day, both on the battlefront and at the
many U.S. military bases located around the world. Of all the
individuals in the United States that have been diagnosed with
mesothelioma cancer, the veteran population has been affected the
most.

The simple reason for this increased risk is
exposure to asbestos. Asbestos, the only known cause of
mesothelioma, was used by the U.S. military in literally hundreds
of applications. Because exposure was unavoidable for some,
mesothelioma remains one of the most serious diseases affecting
veterans today, particularly those who served between World War II
and the Vietnam Conflict.

Asbestos was used in all branches of the military for
many years, especially during the years of World War II and the
Korean Conflict. At that time, shipbuilding was at its peak. In
fact, about 4.3 million Americans worked in
shipyards during World War II and because of the daily tasks
they were required to perform, many were at risk for developing
asbestos-related diseases.

Navy veterans are at the greatest
risk to develop mesothelioma as asbestos was widely used in Naval
ships and shipyards.

Navy veterans were exposed to high levels of asbestos
present in many areas of
navy ships including boiler rooms, engine rooms, galleys and
sleeping quarters. While the soldiers who lived and worked aboard
the ships - including gunmen, boilermen, and firemen - were
susceptible to inhaling asbestos, those who built and repaired the
ships were even more prone to developing diseases associated with
the toxic mineral. They were tradesmen such as pipefitters,
plumbers, mechanics, shipfitters, electricians, welders and
boilermakers to name a few.

There have even been instances where military base
secretaries, and others who did not work directly on ships,
developed
mesothelioma cancer through second-hand asbestos exposure.
Second hand exposure occurs when asbestos dust is inhaled from the
clothes and hair of others who worked with asbestos on the base or
from an abundance of asbestos circulating through the air. Loved
ones of shipyard workers have also been known to develop the
disease due to the same type of secondary exposure.

Because mesothelioma can remain dormant for several
decades, many veterans who served during the 1950s to the 1970s
are just being diagnosed with the disease. These brave men and
women were unaware that they would face a terminal illness in
their later years when they had hoped to be enjoying retirement
and extra time with their family. Mesothelioma is a particularly
difficult disease to battle, and though there have been great
advances in the area of
mesothelioma
treatment in recent years, the overall prognosis for the
disease is not a favorable one.

There has also been some controversy surrounding the
U.S. government and their responsibility to those who have
developed mesothelioma and other asbestos diseases as a result of
their service to the country. While the Veterans Administration
offers some guidance to afflicted personnel, it is clear that more
must be done to support veterans with mesothelioma, including
compensation for medical expenses, loss of income, and suffering.

Veterans diagnosed with mesothelioma might be eligible to
receive financial compensation for lost income or medical expenses.

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